Nurse Care Manager

About the role

The Nurse Care Manager is a field-based role responsible for care coordination of high-risk patients who require comprehensive care plans addressing chronic conditions. This role focuses on chronic care management and care transitions, particularly for patients discharged from inpatient settings, and involves both in-person and telephonic outreach, medication reconciliation, and ensuring continuity of care across the healthcare ecosystem.

Responsibilities

• Develops strong relationships with patients and caregivers, advocating for their needs and ensuring they understand and follow their care plans.
• Works effectively with the multidisciplinary Care Team Pod to ensure seamless care across all providers and services.
• Actively reaches out to patients and caregivers within 48 hours of discharge to ensure smooth transitions and minimize gaps in care.
• Provides clear, compassionate education to patients and families about treatment options and ensures patients are empowered to manage their health.
• Ensures that care is effectively coordinated across multiple providers, institutions, and services, particularly during transitions of care.
• Effectively manages patient caseloads, balancing multiple tasks while adhering to deadlines and care plans.
• Identifies potential gaps in care, resolves issues through collaboration with providers, and works to optimize patient outcomes.
• Maintains patient confidentiality and follows HIPAA regulations to ensure privacy in all interactions.
• Demonstrates respect for diversity, ensuring culturally sensitive care that meets the needs of diverse patient populations.

Requirements

• Registered nursing license (unrestricted)
• Minimum of three years of clinical nursing experience
• PREFERRED: Experience in care management, case management, or transitional care settings; experience in acute care environments such as ICU, Med-Surg, or ER is also highly valued
• Expertise in care management and coordination across healthcare providers
• Strong communication skills for patient and caregiver education
• Experience with EHR systems and real-time documentation
• Able to work independently and manage multiple patient cases
• Critical thinking and decision-making skills in developing care plans
• Proficient in using digital tools for care coordination and communication
• A valid driver’s license and auto liability insurance
• Reliable transportation and the ability to travel within assigned territory or as needed
• CASE MANAGEMENT CERTIFICATION IS PREFERRED BUT NOT REQUIRED

Key Behaviors

• Patient-Centered Care
• Collaboration
• Proactive Communication
• Advocacy and Education
• Care Coordination
• Time Management
• Problem Solving
• Confidentiality
• Cultural Competence

Competencies

• Clinical Expertise
• Effective Communication
• Care Plan Development
• Technology Proficiency
• Outcome-Oriented
• Independent and Team-Oriented
• Critical Thinking
• Multitasking and Prioritization
• Patient Engagement

Upward Health Benefits

Upward Health offers a comprehensive benefits package including health insurance, retirement savings plan, paid time off, and more. We are committed to providing a supportive and inclusive workplace environment.

Upward Health Core Values

We value innovation, collaboration, integrity, and compassion in all aspects of our work. Our core values guide us in delivering exceptional care to our patients and fostering a positive work culture.

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